A mental health patient was found hanged after medics failed to give him the support he desperately needed - even after he walked onto a ward with cuts on his arms and knives in his hands, an inquest heard.

The family of Bernard Phillips, 35, have slammed North Manchester General Hospital after a coroner ruled there had been a catalogue of ‘systemic failures’ in his care.

Bernard, who suffered from chronic bipolar affective disorder, was found hanged in October 2015, two days after waiting over an hour to be seen by any staff at A&E.

Such was his distress, he self-harmed in the waiting room toilet before walking onto a ward where he was spotted by a doctor who confiscated the knives and treated his wounds.

But staff then failed to refer him for mental health assessment and he was allowed to walk out of the hospital without the help he desperately needed.

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Pennine Acute Hospitals NHS Trust and Greater Manchester Mental Health NHS Foundation Trust say they have reviewed and improved their policies around such cases, and the coroner noted that many of the recommendations made were already taken up by trust bosses.

After the inquest, Bernard’s mum Lucy Morgan, 52, from Blackley, told the M.E.N: “We have been left devastated by Bernard’s death. He was my son and also my best friend.

“Lessons need to be learnt. How many more deaths before somebody actually sits up, listens and does something about it?

“If what has happened to Bernard saves just one life his death will not have been in vain.”

At his inquest, sitting at Manchester Crown Court, Coroner Jean Harkin noted ‘systemic failures’ and drew comparisons with the case of Nicky Sullivan , who waited for 80 minutes to be seen at North Manchester A&E before walking into a road in November 2014.

Noting a ‘series of failures by A&E staff and mental health staff’, she said Bernard, whose condition meant he heard voices and had thoughts of harming himself and others, was left in a waiting room for over an hour - when he should have been seen in 15 minutes.

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She said this meant his condition was allowed to deteriorate, he was not given a mental health assessment and he resorted to self-harm.

Recording a narrative verdict, she added: “Standard operating procedures were not followed, the clinical notes system was not updated, the missing patient policy was not followed and the family were not informed of the deceased’s deteriorating mental health and attendances at A&E.

“As a result of these failures the deceased did not receive the support that would have provided treatment, reassurance and the transfer of information that would probably have prevented his premature death.”

She ruled Bernard had died in a deliberate hanging but without the intention to kill himself.

She said the trusts’ own investigations into Bernard’s death had been thorough and many of its recommendations were already taken up, but warned she would be ‘keeping a close eye’ on the trusts in future.